166 lines
8.8 KiB
HTML
166 lines
8.8 KiB
HTML
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<!-- Main content -->
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<section class="content">
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<div class="row">
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<!-- right column -->
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<div class="col-md-12">
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<!-- Horizontal Form -->
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<div class="box box-info">
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<div class="box-header with-border">
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<h3 class="box-title"> Enter Your Information Below</h3>
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</div>
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<!-- /.box-header -->
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<!-- form start -->
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<form class="form-horizontal" id="inputformId" method="post" enctype="multipart/form-data" action="__SERVER_URL__webroot/Staff/RTG-CITADEL-ALL-BUREAU-ALL-DEROGATOR-first-WAVE-onslaught-to-be-UPLOADED-FAXED-and-MAILED.php">
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<div class="box-body">
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<div class="row">
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<!-- right column -->
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<div class="col-md-10">
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<div class="form-group required">
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<label class="col-sm-5 control-label">CRA REPORT # </label>
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<div class="col-sm-7">
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<input type="text" name="experian_report" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">Your First & LAST name,Your Street NUMBER & Street NAME ,and Your City and State are as Follows</label>
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<div class="col-sm-7">
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<textarea name="name_address" class="form-control" rows=8 required ></textarea>
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">Credit Bureau & Credit Bureau ADDRESS per Credit Report EXACTLY as displayed:</label>
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<div class="col-sm-7">
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<textarea name="records1" class="form-control" rows=10 required ></textarea>
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">Below are the accounts in question: Creditor(s) alleging the negative item(s) and alleged account number(s)
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and or description(s) of the NOT PROVEN CURRENT,TRUE, ACCURATE, COMPLETE, TIMELY,
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MINE,MY RESPONSIBILITY, and or elsewise lawfully adequate for ethical reporting:</label>
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<div class="col-sm-7">
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<textarea name="records2" class="form-control" rows=10 required ></textarea>
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">BELOW are the Misinformation being Mis-reported or are in question. You MUST report PROPERLY,the
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Claims below REQUISITE immediate eradication for adequate and lawful FCRA reporting particularly per
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Metro 2 Compliance regulations:</label>
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<div class="col-sm-7">
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<textarea name="records3" class="form-control" rows=10 required ></textarea>
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">BELOW are the Misinformation being Mis-reported or are in question. You MUST report PROPERLY,the
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Claims below REQUISITE immediate eradication for adequate and lawful FCRA reporting particularly per
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Metro 2 Compliance regulations:</label>
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<div class="col-sm-7">
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<textarea name="records4" class="form-control" rows=10 required ></textarea>
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</div>
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</div>
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<div class="form-group ">
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<label class="col-sm-5 control-label">Proof of identification<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-5">
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<input type="file" onchange="uploadphotos(this)" name="image1" id="image1" class="form-control" >
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<input type="hidden" value="" name="image1" id="image1new" class="form-control" >
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</div>
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<div class="col-sm-2">
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<a style="cursor:hand;cursor:pointer;" onClick="clearImage('image1');" data-id="4">Clear</a>
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</div>
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</div>
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<div class="form-group ">
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<label class="col-sm-5 control-label">Proof of residence or mailing address<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-5">
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<input type="file" onchange="uploadphotos(this)" name="image2" id="image2" class="form-control" >
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<input type="hidden" value="" name="image2" id="image2new" class="form-control" >
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</div>
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<div class="col-sm-2">
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<a style="cursor:hand;cursor:pointer;" onClick="clearImage('image2');" data-id="4">Clear</a>
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</div>
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</div>
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<div class="form-group ">
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<label class="col-sm-5 control-label">Proof of social security number<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-5">
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<input type="file" onchange="uploadphotos(this)" name="image3" id="image3" class="form-control" >
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<input type="hidden" value="" name="image3" id="image3new" class="form-control" >
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</div>
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<div class="col-sm-2">
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<a style="cursor:hand;cursor:pointer;" onClick="clearImage('image3');" data-id="4">Clear</a>
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</div>
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</div>
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<div class="form-group ">
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<label class="col-sm-5 control-label">Your Notarized Letter/form Here(if needed)<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-5">
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<input type="file" onchange="uploadphotos(this)" name="image4" id="image4" class="form-control" >
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<input type="hidden" value="" name="image4" id="image4new" class="form-control" >
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</div>
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<div class="col-sm-2">
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<a style="cursor:hand;cursor:pointer;" onClick="clearImage('image4');" data-id="4">Clear</a>
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</div>
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</div>
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<div class="form-group">
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<div class="col-sm-offset-5 col-sm-4">
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<button type="button" onClick="resetForm()" class="btn btn-info pull-left">Reset
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</button>
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<button type="submit" class="btn btn-info pull-right">Generate
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PDF</button>
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</div>
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</div>
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</div>
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</div>
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</div>
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<!-- /.box-body -->
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<div class="box-footer"></div>
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<!-- /.box-footer -->
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</form>
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</div>
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<!-- /.box -->
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</div>
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<!--/.col (right) -->
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</div>
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<!-- /.row -->
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</section>
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<!-- /.content -->
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<script type="text/javascript" src="../common_image_type.js"></script> |